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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTH AFARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6M-4 JA,12Sam-� LO a� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 1 <br /> FACILITY NAME <br /> S rTp • 1 O I <br /> SITE[AD�D)RESS til�� • � v�� rj'T'pC�T(�JV <br /> —( / Street Number Direction ` Street Name CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /S \JG <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 's <br /> PHONE#1 ExT• APN# L.AND USE APPLICATION# <br /> (17 C,,n �2S, T7 ZZ' <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS(NAME PHONE# EXT, <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/Or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that the work to be p rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar TE and FEDER laws. <br /> APPLICANT'S SIGNATURE: / DATE: 3 Z <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,Proof Of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It ISproVlded to me or <br /> my representative. p <br /> TYPE OF SERVICE REQUESTED: F,G <br /> cw <br /> COMMENTS: 2 �� SA APR 0 8 2015 <br /> EN At7wry <br /> yFAl.TH�F Ap MI. <br /> ACCEPTED BY: EMPLOYEE#: DATE: 06 <br /> �r <br /> ASSIGNED TO: EMPLOYEE#: DATE: IF <br /> Date Service Completed' SERVICE CODE: P I E: <br /> Fee Amount: Z �D Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />